MEDICARE: TIM ENEVOLDSEN M.ED., LPC-S, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	10727	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184174609
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIM ENEVOLDSEN M.ED., LPC-S, PLLC

Provider Business Mailing Address
First Line	:	6666 W AMARILLO BLVD
Second Line	:	SUITE 4
City	:	AMARILLO
State	:	TX
Zip	:	79106-1756
Country	:	US
Telephone Number	:	806-570-3775
Fax Number	:	806-358-3627

Provider Business Practice Location Address
First Line	:	6666 W AMARILLO BLVD
Second Line	:	SUITE 4
City	:	AMARILLO
State	:	TX
Zip	:	79106-1756
Country	:	US
Telephone Number	:	806-570-3775
Fax Number	:	806-358-3627

Authorized Official
Title or Position	:	THERAPIST
Name	:	MR. TIMOTHY JOHN ENEVOLDSEN
Credential	:	M.ED.,LPCS,LMFT,LCDC
Telephone Number	:	806-570-3775

Provider Enumeration Date	:	10/07/2016
Last Update Date	:	10/07/2016

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